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Rapid Responses: Rapid Responses published:
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Of course other trauma can cause retinal haemorrhage
- Brett Halliday (26 March 2004)
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apples to oranges
- Heather J Lohr (27 March 2004)
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What are your feelings on this ?
- Lois Herlihy (27 March 2004)
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Mechanism of formation of peri-macular folds
- Richard M Gregson (30 March 2004)
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Killer Televisions
- Debra D. Esernio-Jenssen (1 April 2004)
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Re: Killer Televisions - Give us a break!
- Heather Lohr (1 April 2004)
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Re: Mechanism of formation of peri-macular folds
- L. Travis Haws (1 April 2004)
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Accidental and non-accidental shaken brain injuries
- Robert Sunderland (2 April 2004)
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Re: Killer Televisions
- Patrick E. Lantz (3 April 2004)
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Is the current SBS diagnostic criteria science, or assumption?
- Hilary Bulter (4 April 2004)
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Re: Re: Killer Televisions
- Heather Lohr (5 April 2004)
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The Flying TV Syndrome
- Fikri M Abu-Zidan, Johan Johansen (14 April 2004)
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Retinal signs in shaken baby syndrome-an ophthalmologist's perspective
- Scott J Robbie (24 April 2004)
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Re: Retinal signs in shaken baby syndrome-an ophthalmologist's perspective
- Heather Lohr (25 April 2004)
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Brett Halliday, Consultant Ophthalmologist The Coplow Day Case Cataract Unit, Meriden, CV7 7JR
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With a clear history of trauma it was remarkably stupid for the paediatric ophthalmologist here to conclude that the retinal haemorrhages were specific for shaken baby syndrome. I gave evidence in a criminal case a couple of years ago where a baby was found at the foot of some stairs with a skull fracture. Retinal haemorrhages were found and another ophthalmologist used these as evidence that the baby had been shaken. This was of course an incorrect conclusion; trauma sufficient to fracture a skull can cause retinal haemorrhage and there is plenty of literature to show this. The problem now is that the pendulum may swing the other way and retinal haemorrhage (which I still believe is reasonable marker of shaken baby syndrome where there is no other evidence of trauma or bleeding disorder) may be discounted by the Courts and at risk babies may remain at risk of further abuse. Competing interests: None declared |
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Heather J Lohr, parent 16652
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This report is no surprise to those of us who have been falsely accused. I propose yet another thought on the subject of perimacular folds. We have seen alleged cases of nonaccidental injury with perimacular folds, we have now seen cases of accidental trauma with perimacular folds, we have seen adults with perimacular folds in the form of Tersnon's syndrome. I propose that the medical community stop acting like babies are apples and adults are oranges. If an adult can develop perimacular folds without traumatic pathology, it is logical that this can also happen in an infant. In fact it likely has happened often but the accusational medical community has refused to see the logical and have adapted the definition of SBS to include anything it feels will help them keep the truth from being known. I thank the authors of this report for taking the bull by the horns and pointing out the problems with the current method of diagnoses. Competing interests: involved in investigation |
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Lois Herlihy, none 33029
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Retinal Hemorrhages caused by CPR, anoxia also hemorrhages in relationship to diabetics as well as betamethasone (corticosteroid) use in pregnant women? Do you not agree that everything should be examined PRIOR to going with the SBS theory? What about this hypothesis Corticosteroid administered at high doses induces diabetes, hypertension, brain atrophy, and increases capillary fragility and abnormal vascular growth in the retina? Thank you for reviewing this information I am loooking forward to the response Competing interests: None declared |
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Richard M Gregson, Consultant Ophthalmologist Queen's Medical Centre, Nottingham, UK
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Far from belying the possibility that non-accidental injury is most likely cause of this retinal sign, I think that it confirms the theory of Betz et al. as to the mechanism of ocular damage in shaking injury. In their theory, thoracic compression, by the perpetrator of a shaking episode, causes reduced cardiac pre-load and increased venous engorgement of the head and neck. To- and fro- shaking causes a retrograde venous pressure wave from the cerebral venous sinuses to the eye via the valveless ophthalmic vein. The ophthalmic veins turn through 90 degrees as they leave the eye via the optic disc: a powerful pressure wave in these veins would stiffen them, and, rather like a garden hose connected to the mains, cause them to straighten. If powerful enough, this straightening would elevate the veins from the vascular arcades and cause the peri- macular folds seen by Lantz et al and in severe cases of 'shaken baby syndrome'. It is not, I believe a direct effect of the shaking that produces the widespread hemorrhages and retinal folds, but a secondary one. This theory explains why these physical signs are not seen in cases of where there is rapid in- and out- eye movement (such as the nystagmus seen in Parinaud's syndrome) nor usually after single deceleration events, such as fatal falls, when this venous pressure wave may not occur, or be directed in a different direction. I would argue, then, that although it is clear from this report that peri- macular folds cannot be pathognomonic of shaking injury, the presence of these folds indicates an highly unusual form of trauma for which reasonable explanation must be sought in each case. Competing interests: None declared |
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Debra D. Esernio-Jenssen, Director Child Protection Center Schneider Children's Hospital
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There are several important historical, social and developmental history that was not delineated in this case report. Nor were admission laboratory values, radiographs, and physical examination noted, as well as more details about the child's hospital course. There also was no mention of existing literature on television toppling injuries. It would be important to know, for example how exactly the father found the child. It is not stated if he was face up, prone, or on his side. Was any blood present, from the childs nose, mouth, skull? Was there evidence of "cooking" in the kitchen? Why did he not telephone 911? There is no mention of what he informed happened to his child to the neighbor who drove them to the hospital. They report that a "greasy smudged area" on the TV glass corresponded to the impact site on the child's head-but did not report the location of the impact site. With symmetrical parietal skull fractures a severe trauma to the crown or occiput would be expected. Were there any previous injuries to this child or prior child protection reports. Was there family discord, known drug or alcohol use, or financial stressors? How were the children disciplined? What were the developmental capabilities of this child? Was he standing, walking, and able to climb? How verbal was the 3 year-old sibling? Was he talking in complete sentences, does he understand cause and effect? When he arrived at the hospital, what was this child's vitals, arterial blood gas, CBC, LFTs, coagulation studies? Any other cutaneous manifestations of abuse? If the television landed on his anterior chest, were there rib fractures or pulmonary hemorrhaging? There is no skeletal survey report mentioned. Was it done? Why was there no mention of prior literature on television injuries. The Consumer Product Safety Commission statistics were not mentioned. How many children in the past have died from television toppling? How many with perimacular retinal folds? Was a report about this child sent to the CPSC? And finally, many perpetrators of Shaken Baby Syndrome cite accidental injury as a cause of the physical findings in their victims. Twenty minutes is ample time to shake a toddler to death. The television certainly may of toppled onto the floor, angering the father, who then shook the crying, frightened toddler. His 3 year old sibling said "television fell", there was no detailed report of his forensic interview. This alleged accident was NOT witnessed by a non-family member. Furthermore too much data pertaining to this case was not included in the case report. Without providing the details of the aforementioned information requested, the authors' conclusions seem unfounded. Competing interests: None declared |
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Heather Lohr, parent 16652
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Why do you insist on turning tragic accidents into child abuse??!! ACCIDENTS HAPPEN! Most certainly children have been killed from falling TVs. That's why parents are advised not to place them on top of dressers, etc. that could topple over when weight is set on the front. There are advisories to warn parents of this very scenario. Why is any accident that does not have a non-family member witness automatically considered child abuse in your book? Why not begin to prosecute parents of children who suffer traumatic subdurals from falls and car crashes. Maybe they were shaken to death first then tossed out the window? This is so ridiculous! This is what the public needs to see. Thank you for showing the blood-thirsty mentality of the wonderful children's advocates known as child protection workers. Yes, the death of any child is tragic and sometimes very avoidable but not all deaths are related to abuse. This was clearly an avoidable accident. So fault the dad for not keeping a better eye on this child but DO NOT try to turn it into something it was not. The investigation has shown that is was an accident. Many people do not call 911. They reason it is quicker to drive the injured in themselves. Is it the smart thing to do? If it would take 6-7 minutes for help to arrive and you are 8 minutes from the hospital yourself, what would you do? If you wait 6-7 minutes for EMS, then they still have 8 minutes from the hospital! Stop second guessing. You cannot change the outcome of this report. This report clearly points out the problem with shaken baby syndrome. It shows clearly that perimacular folds have only been reported as caused by abuse in infants (sbs) to date and that as far as they can see, there is no evidence to back it up. What has happened is that there have been reports of folds, retinoschisis, retinal hemorrhages, etc., in infants suspected to have been shaken. But I ask the same question you did --- were there non-family members who witnessed this alleged shaking? I think not. Reports of independently witnessed shaking baby syndrome are not to be found! It's never been reported! So how can anybody sit there and claim that because it was suspected to be shaking it was and therefore these folds, schisis cavities, etc., only come from shaking? I have had enough of this! The Cleveland sex scandals, the Sir Roy syndrome ... it has gone far enough. The child protection people have done very well in trying to establish a need to keep them employed with our tax dollars. I call you to the table. SHOW US ONE REPORT OF AN INDEPENDENT NON-FAMILY MEMBER WITNESSED CASE OF SHAKING BABY SYNDROME THAT DID NOT CULMINATE IN IMPACT. I WANT A SIMPLE SHAKING-ONLY CASE REPORT WITH SWORN TESTIMONY OR BETTER YET VISUAL EVIDENCE. I DON'T WANT CASES OF CONFESSION AFTER 10 INTERVIEWS BY POLICE. I DON'T WANT MOM PITTED AGAINST DAD. I DON'T WANT A REPORT OF A PANICKED PARENT SHAKING AN ALREADY SEEMINGLY LIFELESS CHILD. SHOW ME ALL THE EVIDENCE THEN ON THIS CHILD, LAB VALUES, COAG STUDIES, CULTURES, PREVIOUS HISTORY. SHOW IT TO US. WE ARE WAITING!!!! Competing interests: None declared |
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L. Travis Haws, Dentist DFC 12860 West Cedar Drive Lakewood, CO 80228
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Editor: Admittedly I am not an ophthamologist nor a medical doctor, but have a medical/dental background, have had gross anatomy, extensive head and neck anatomy...have repaired orbital floor fractures, zygomatic maxillary complex (ZMC) fractures, orthognathic surgery...taken all the requisite physiology, physics, biochem, pathology...courses to obtain my doctorate degree. In addition, dentistry entails studying, in depth, the nature of compressive, tensile, flexural, shear forces... I feel I must respond to the letter by Richard M. Gregson as I believe this is a great and "classic" example of how we got where we are today. By haphazardly flinging out theories as if they are a matter of fact. While concomitantly, consciously or unconsciously, ignoring other very applicable facets to the whole picture. As stated by Dr. Gregson, "I think that it CONFIRMS the theory of Betz et al." Allow me a minute to discuss why I think his belief of confirmation of the Betz et al. theory, and the reasoning thereof, is haphazard, baseless and perhaps even reckless: First and foremost, no such "shaking" events transpired in the case presented by Lantz et al. (to my understanding a TV toppled over onto a 14 month old). Nor is there any evidence or reasons to believe this child was being squeezed, to increase the venous pressure of the head and neck, prior to the TV toppling. Perhaps he was severely constipated and trying to take a bowell movement? In contrast, it's more like the "single deceleration" event (if even that), that does not result in these physical findings according to Gregson. Secondly, the narrow lumen of superior and inferior ophthalmic veins (as compared to the venous sinuses) in addition to the 90 degree turn (as described by Gregson) and the direction the blood is naturally flowing will resist the flow of this so called retrograde "pressure wave". This is a basic principle of physics. So what prevents the blood from just "sloshing" around in the sinus, resisting this "retrograde flow" or a further increase of sinus pressure...? As well, the two ophthalmic veins have many contributing tributaries, which would help disperse this "pressure wave". The opthalmic vein Gregson discusses, is not the only vein draining into the cavernous sinus. Thirdly and very importantly, the veins are not floating in free space, they are embedded in fascia, connective tissues, fatty tissues (i.e. the superior ophthalmic vein courses with the artery and passes through the two heads of the lateral rectus muscle and the superior orbital fissure)...that are all encased in muscle and bone. Take the garden hose example, and embed it in dirt and let the "pressure wave" loose. I would suspect that before the 90 degree turn straigtens, the hose would either burst, or the pressure within the hose would just increase (resulting in engorgement of the hose or increased hardness). In order for the vein to straighten, the "pressure wave" would have to overcome the compressive resistance applied from the bodily tissues on the internal aspect of the 90 degree turn and simultaneously overcome the tensile resistance applied from the bodily tissues on the external aspect of the 90 degree turn, and a combination of forces between the two (i.e. tensile, shear, compression, flexural). Let alone the resistance of the bent vein itself to deform and the resistance of the retina to detaching. For example, the hose in the dirt would have to break free of the encased dirt, that is attached and circumferentially surrounds it, by pushing and pulling the dirt before it is able to straighten. In addition, it would have to overcome its own resistance to straightening (deformation) as well as pushing in a convex bladder/diaphram (peri-macular folds) that it is attached to. If the force required to do this exceeds the force to burst the hose, then the hose will simply burst (that is just one example of the many forces at play). It seems Gregson actually gave more support to the mechanism that retinal hemorrhages are a result of increased intracranial pressure impeding blood flow within the central retinal vein (i.e. central retinal vein occlusion) as cited by many authors. For example, his explanation of "venous engorgement of the head and neck" more adequately correlates with increased intracranial pressure cites than does this "pressure wave" theory. It takes an orbital floor fracture for the eyeball to sink inferiorly a few millimeters, yet the SBS proponent "experts" talk as if the eyeball is "bouncing" around in the bony orbit, like a pinball, during "shaking" episodes. Let's not forget that the eye has many ocular muscles and is surrounded by glands, fatty tissues, fascia...all encased in a bony orbit. As well, to "oscillate" the vitreous and cause traction on the retina, the eyeball itself must deform as liquids/gels that are contained in and completely fill the inner eye are not readily compressible (another basic physics principle...how does brake fluid work, it does not compress, so it pushes the brake pads against the rotors, but if their is air in the brake line, then it will compress and less force is applied to the rotor...i.e. hydraulics). Now, recall that the eyeball is contained itself as previously mentioned, so deformation of the eyeball would also be rather difficult without direct trauma/blow to the globe. Then again, I am no ophthamologist or biomechanical expert. This is my opinion from my understanding of mechanics, physics, anatomy, physiology... The last thing I want to do is fling science around haphazardly, especially when peoples families and lives are at stake. To me, child abuse is horrific, but pales in comparison to the, all to easy, complete and utter destruction of innocent grieving families. Especially when based upon opinion and hearsay or "confirmed" by interrogations "seeking" the "truth" in the name of "justice". L. Travis Haws Note, anatomical references cited from Gray's Anatomy. Henry Gray (1821–1865). Anatomy of the Human Body. 1918. Competing interests: Know the Falsely Accused |
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Robert Sunderland, Paediatrician Birmingham Children's Hospital, B4 6NH
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British judges have long recognised the tension in medical evidence. The prime responsibility on paediatricians is to protect children. This includes enhancing family life as well as reducing exposure to danger (from accidental and non-accidental causes). The legal process seeks guidance on interpreting information to determine the probability that a series of findings have a natural or unnatural explanation. This may be easier for financial or engineering experts where facts are black and white. Apart from birth and death, most medical evidence deals in shades of grey. One of the problems in finding an explanation for abnormalities in young children is that they cannot give an explanation themselves. The story is obtained from carers who may have reason to conceal, confuse or confabulate. Law enforcement agencies look to outside experts to explain the normal range of variation and natural processes. They are not helped by confident conclusions based on presumptive speculation if these are erroneous. Mrs Justice Bracewell put this succintly 'Much research contains a circular argument where the likely cause (accidental or non-accidental) is decided by the authors who then proceed to analyse their data and conclude that certain types are typical of their attributed aetiology.' Such work is of necessity dependent upon a limited number of cases which will have been selected by referral and is dependent upon a diagnosis which involves assumptions about the underlying history that may not have been tested evidentially or established as fact.(1) Mrs Justice Butler-Sloss identified the difficulty in determining whether an injury has an innocent cause 'it is difficult to find enough normal children on whom these tests can be done because, for obvious reasons, parents may not be anxious for doctors to do so'. She observed that the conflict between doctors as to aetiology of some findings 'is not helpful to the measured dispassionate approach necessary in future to deal with such sensitive and difficult problems.(2) Child abuse is both emotive and emotional. This difficult work is not lightly undertaken and is increasingly unpopular. Unreasonable expectations of confident diagnosis may lead to overconfident dependence on untested signs which serves not only to devalue the experts and their evidence but may leave abused children unprotected. References 1.Bracewell J. Manchester City Council v B. Family law Reports 1996; 1: 324-333. 2. Butler-Sloss J. Medicine and the Law (Ed D Brahams). Royal College of Physicians of London. 1989: 59-69. Competing interests: Have assisted police, parents and social services in investigating children's injuries, including giving evidence to Courts. |
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Patrick E. Lantz, Associate Professor Department of Pathology, Wake Forest Unversity School of Medicine, Winston-Salem, NC 27157 USA
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There are several important historical, social and developmental history that was not delineated in this case report. Nor were admission laboratory values, radiographs, and physical examination noted, as well as more details about the child's hospital course. There also was no mention of existing literature on television toppling injuries. -BMJ has a 1200 word limit on case reports and the print version has a limit of 24 references. That’s why the additional references and Table are not in the print edition. The original manuscript cited articles re toppling TVs by C. DiScala and Bernard but they were dropped due to space limitations. It would be important to know, for example how exactly the father found the child. It is not stated if he was face up, prone, or on his side. -On his back with the left side of his face down. Was any blood present, from the childs nose, mouth, skull? -Nose, no; mouth, no; skull, yes, internally associated w/ the bilateral skull fractures. Was there evidence of "cooking" in the kitchen? -Yes Why did he not telephone 911? -His wife was a health care provider; he called her, told her what happened and to meet him at the hospital. They live in the country and the responding emergency service would have been the volunteer fire department. There is no mention of what he informed happened to his child to the neighbor who drove them to the hospital. -Same story, it never changed. They report that a "greasy smudged area" on the TV glass corresponded to the impact site on the child's head-but did not report the location of the impact site. -Impact to right side of head centered over right ear w/ pinna pressed against scalp leaving curved contusion. With symmetrical parietal skull fractures a severe trauma to the crown or occiput would be expected. -Or side-to-side lateral impact with quasi-static loading. Were there any previous injuries to this child or prior child protection reports. -No and no. Was there family discord, known drug or alcohol use, or financial stressors? -None noted by the detectives or the paediatric child abuse expert. How were the children disciplined? -I don’t know but there was no evidence of physical torture. What were the developmental capabilities of this child? Was he standing, walking, and able to climb? -Age appropriate, could stand, walk and climb up onto chairs, couch, etc. How verbal was the 3 year-old sibling? Was he talking in complete sentences, does he understand cause and effect? -Short phrases – but I don’t think he fully understood that a participial phrase at the beginning of a sentence must refer to the grammatical subject. Understood cause & effect(age appropriate). When he arrived at the hospital, what was this child's vitals, arterial blood gas, CBC, LFTs, coagulation studies? -GCS: 6; don’t have VS in autopsy file but can retrieve it from medical record if you think it’s critical ABGs: acidotic w/ pH of 7.18 and lactate of 13.3 CBC: WBC: 25.4K; RBC: 2.69M; Hgb: 7.8; PCV: 22.4; PLT: 91K PT: 17.1; INR: 1.86; PTT: 50.1 Acidosis, anemia and coagulopathy corrected in PICU. No record of LFTs done. Any other cutaneous manifestations of abuse? -What other cutaneous manifestations of abuse? The RHs and perimacular retinal folds (PRFs) were the only suggestions of abuse. He had no other injuries other than that attributable to the toppling TV set. If the television landed on his anterior chest, were there rib fractures or pulmonary hemorrhaging? -No rib fractures; intra-alveolar extravasated blood due to DIC. There is no skeletal survey report mentioned. Was it done? -Yes: premortem and postmortem. Skeletal survey showed no fractures except for parietal skull fractures. Why was there no mention of prior literature on television injuries. The Consumer Product Safety Commission statistics were not mentioned. How many children in the past have died from television toppling? -Search Medline w/ ‘television + head injury + accident’; four current articles pertaining to morbidity and mortality of toppling TVs and children. Abstracts previously sent to you. How many with perimacular retinal folds? -Three studies used databases. Email from Ed Barksdale at CHP (Pittsburgh not Philadelphia) indicated that no one looked. Our article indicated that we could find no previous case reports/series of PRFs in accidental head trauma in children. Was a report about this child sent to the CPSC? -OCME in Chapel Hill would do that. And finally, many perpetrators of Shaken Baby Syndrome cite accidental injury as a cause of the physical findings in their victims. Twenty minutes is ample time to shake a toddler to death. The television certainly may of toppled onto the floor, angering the father, who then shook the crying, frightened toddler. His 3 year old sibling said "television fell", there was no detailed report of his forensic interview. -Sara Sinal has done suspected child abuse interviews/evaluations for over 20 years and in my book she is ‘first among equals.’ She thought that the father was truthful and the only aspect that was worrisome was the ocular findings that she couldn’t explain. This alleged accident was NOT witnessed by a non-family member. -Accidents only happen if witnessed by a non-family member?? Furthermore too much data pertaining to this case was not included in the case report. Without providing the details of the aforementioned information requested, the authors' conclusions seem unfounded. -You neglected to mention our review of the literature re PRF in abusive head trauma. A brief primer about scientific methodology or the principles and empirical processes of discovery and demonstration deemed necessary for scientific investigation. 1. Observation(s) of phenomena 2. Hypothesis formulation about phenomena 3. Experimentation to demonstrate truth or falseness of hypothesis 4. Conclusion that validates or modifies hypothesis Regarding diagnostic specificity of PRF and causal mechanism. Previous authors have skipped over #3 something like this: 1. Observation: PRF + RH observed in children diagnosed w/ abusive head trauma 2. Hypothesis: PRF is caused by vitreoretinal traction during cycles of acceleration/deceleration (shaking) 3. Experimentation: NONE 4. Conclusions: PRF is due to vitreoretinal traction and diagnostic of shaking injury So what has arisen is a fallacy of assumption. Prior to our case report and literature review if someone observed PRF in a child w/ a head injury then he/she would diagnose NAHI no matter what the circumstances. In fact this is what the American Academy of Ophthalmology (AAO) website states: “When extensive retinal hemorrhage accompanied by perimacular folds and schisis cavities is found in association with intracranial hemorrhage or other evidence of trauma to the brain in an infant, shaking injury can be diagnosed with confidence regardless of other circumstances.” http://www.aao.org/aao/education/library/shaken_baby.cfm#ocular Competing interests: None declared |
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Hilary Bulter, freelance journalist home
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Dear Sir, I would like to thank, Professor Lantz, for his courageous article, and second response above. Reading these rapid responses to the facts about the above case, has been a fascinating ongoing view of the current nature of the SBS debate..if you can call it debate. For upon what foundation is the actual house built? Brett Halliday an ophthalmologist, is quite convinced that your case has a clear history of trauma, and also recognises that a baby can be shaken, and is concerned at the pendulum becomin unbalanced the other way. Heather Lohr is a parent who has obviously been falsely accused. And feels justifiably aggrieved at what was patently unfair in your case, as she sees it. Lois Herlihy points out some key anomalies in the baseline theory of **retinal hemorrhages**. Richard Gregson, another Consultant Ophthalmologist, is completely the opposite to Brett Halliday, and clearly leans towards stating that the father injured the child. But what is interesting to me, is that in order to allude to this, he appears to subscribe to the Gold Effect Fallacy, Bellman's Fallacy, the Fallacy of Authority, the Fallacy of obfuscation(1). He too, clearly believes the Father is "guilty" as charged, even though, unlike yourself, he wasn't there..... Again, on what foundation is his house built? As Skrabanek and McCormick also say, on page 35 (1): ***Fashions in medical treatment are the rule, and if they are supported by the voice of authority are difficult to dislodge before they decline into inevitable and tardy death.**** Then enters Debra Esernio-Jenssen, clearly someone else whose first thought is that it is never wise to ever believe anything a parent ever says,or a child... only a non family witness. Hmmm... It appears she also thinks that every parents should be viewed as a perpetrator or worse. She demands answers to suit her own preconceived ideas. Heather Lohr's response to her was totally understandable. L Travis Haw's response was a mastery of logic. But one which will no doubt escape at least two of the above-mentioned "experts" And hopefully, Professor Lantz's reply to Jenssen, will open up the possibility in the latter's mind, that there are other possible causes.... That just maybe falling televisions, and not necessarily parents, can indeed be killers. But to take Lois Herlihy's thoughts further, might not the medical profession need to ask of themselves some serious questions? Should there not be some REAL scientific baseline established, of all the natural non-abuse circumstances whereby retinal haemorrhages ARE seen? For instance, has there ever been a study of all babies born in one hospital over a year in the UK, to see how many babies, after a vaginal delivery, have retinal haemorrhages. Or even haemorrhages anywhere else in the head. After all, it is not unusual to see newborn babies with haemorrhages in the whites of the eye. Might they also have them in the retina as well? Might it not also be a good idea to do a similar study on all children under 1 year of age, admitted with any illness, to see how many of them have retinal haemorrhages as well? And while we are at it, maybe all vehicle accident victims, and all children who break bones falling off playground equipment or falling off bikes, could be likewise studied? We NEED to know how and when these haemorrhages actually occur in real life. Parents DON'T need some sort of retrospective "fallacy" accepted as "mantra", inflicted on them, at the whim of a few people in the medical profession who appear to trust nothing except their own preconceived dogma. Surely there is a lesson to be learned as to how someone such as Professor Sir Roy Meadows could be so easily accepted as an "expert" on anything, given the flimsy, unscientific basis of his "experthood". Unfortunately, there would be one major "hesitation" in the minds of participants with regard to any study looking at retinal/brain haemorrhages in newborns, under ones and children. And that is that IF such studies were conducted under the present blinkerred presumptive view, ..... and WERE it found that retinal and other haemorrhages were actually far more common than previously thought ... just .... maybe ........ ALL participating obstetric staff, parents of babies, or children, who might show as having haemorrages, MIGHT ALL end up being accused in court of shaking their children to injury or death... All in order, perhaps, to protect the reputations of those whose prior prestige came from upholding a previously falacious dogma????? How many more parents, like the father/family above, have to needlessly suffer because Child Protection Services believe in literature which Professor Lantz characterised above as resting on a : **** a weak scientific evidence base. 11 *** Which has: **** Selection bias, inappropriate controls, and the lack of precise criteria for case definition were identified as important problems with the data. **** Many studies committed a fallacy of assumption, selecting cases by the presence of the clinical findings that were sought as diagnostically valid. **** Unsystematic reviews and consensus statements often mingled opinion with facts and added no original supporting evidence. ***** So I would like to know >>>>>What are all the conditions in which retinal/brain haemorrhages can and do occur?<<<<< Studies to elucidate that should include everything including diabetes, corticosteroid use (in fact any prescription medication that alters the bodily uptake of Vitamin C, or any other part of the clotting mechanisms, or could contribute to vascular fragility) .... , childbirth, infection, vehicle accidents, bike and playground accidents ~ if fact everything that includes known biochemical or trauma factors that cause retinal haemorrhages. As part of that, compulsory enquiry should include the issue of increased capillary fragility in view of the work on Professor C. Alan B Clemetson, who wrote a three volume clinical text on Vitamin C (CRC Press) in 1989. These three volumes should form the platform for this study. He devotes a whole chapter to the underlying mechanisms behind the relationship of subclinical ascorbic acid deficiency, retinal haemorrhages and other key medical conditions which are "epidemic" in this world today. Somehow, the current "experts" feel that everyone gets enough vitamin C, and that it was only an issue in the days of the sailors. Unfortunately, this view is untrue, and it could be that the medical profession's current paucity of understanding about the extraordinary biochemical role of vitamin C in the bigger picture of the body, is partially to blame for many of today's "ills". This was dramatically illustrated to me not that long ago, while attempting to discuss the issue with some doctors in this country. It was like talking to a brick wall. So I brought out the text books. Not one of these people had seen the text books, let alone read them. So I enquired of the medical libraries, and not one in this country, had any of the ones I have. All these doctors assumed that there wasn't much to know about something that is "just" vitamin C. "Shrug" was the attitude. Never mind that the three volume text set was pretty much just a summary... Unfortunately for parents today, the attitude that only what "we" (the SBS medical/CPS profession) believe has any truth, what "we" **consider** to be fact or the current "dogma", ... has a major down side. It unjustly got parents like Sally Clark and others to the places where they ended up. Because they were not believed. It is time that that current arrogance of ignorance is admitted, and that the "experts" combine their lack of expertise, and find some real answers, based on real evidence, based on solid foundations, from which to attempt to sort out what is accidental / biochemical / infectious, and what is not. Congratulatons to the authors of this study for standing up against the current tide of constant parent bashing, and calling it like it really is. Even if they had to do it politely. Hilary Butler 1) "Follies and Fallacies in Medicine" Drs Petr Skrabanek, and James McCormick Competing interests: None declared |
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Heather Lohr, parent USA 16652
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Thank you Dr. Lantz for clearing this up! I would hate to think that child protection workers have lost sleep thinking an abuser was running around free somewhere. Some people just cannot imagine anything being an accident. When I read your report on this 14-month-old boy I developed a very detailed image in my mind of what would have occurred. I thought of all the warnings I have seen over the years resulting from children toppling dressers, TVs, etc. on themselves after using the drawers as steps. I can't recall seeing any specific literature which reports a child killed by such an accident but I do know there were advisories about the danger of this happening. It is so horrible that this dad was accused to begin with. What a tragedy for the child, him and his family. My son began to walk at 10 months of age. I don't mean creeping around holding onto the couch, he walked. My nephew wasn't walking yet at over a year. Cites by child protection workers of age appropriate behavior have helped lead to convictions. We are all individuals for a reason. We are not little clones all destined to be the same, act the same, react the same. Our health is not the same. The March 27 issue of British Journal of Medicine has given us one very important thing beyond the evidenced-based report involving this 14- month-old child and the editorials callng for further research. It has given us just a tiny glimpse of how far these people will go to prevent the truth. How ridiculous they can be when challenged. We have thousands of convictions based on the opinion of multidisciplinary teams of child protection advocates. These are the people who determine the parent or caregiver is lying and the involved child was abused. This opinion has always worked for them, it has always been sufficient to base their studies and reports on. But now that these studies and reports have questioned the basis of shaken baby syndrome, they pick and choose studies which do not conform (Geddes 2001)(Lantz 2004)to their stance and attack them as not being substantiated, after all they don't even know if it was or wasn't abuse. Despite the finding of their all-powerful multidisciplinary teams, without non-family witnessed confirmation, they claim it is a jump to conclude the objects of these studies were abused or not abused. But I do not see them questioning any of the non-witnessed cases they use as the foundation of their hypothesis (Caffey.) Plunkett's 2001 report of short fall deaths is criticized because the children were a little older. I have seen accusations of sbs involving 3 year olds, preteens, etc. This of course goes back to the apples and oranges thing. I believe it would be more likely for an infant to die from a short fall given the brain does not fill the cavity as well; similar findings have been reported in the elderly whose brains begin to get smaller. We are on the fast track to a police state where children are taken at birth and not given back until they are adults because every parent is expected to be an abuser. Institutions run by child protection workers will be established to care for all the children and we will be assured that not one will ever suffer an accident or cardiac arrest or infection or illness. Some day a powerful politician will be charged with this crime and then we will see action taken. Right now we have a bunch of people who are too busy fighting the charges to get involved with the bigger issue at hand. If everyone who has been falsely accused got up and made a lot of noise about it, we would get somewhere a lot faster. The pendulum is swinging our way and I hope we are ready. The saddest thing that has resulted from this issue of BMJ is that while the news of perimacular folds was covered quite well in Europe, the United States did not pick it up. The major news sources chose to ignore this and instead ran more sad stories of convictions of the accused. The timing must not suit in the United States where April is National Child Abuse Prevention Month. I saw relatively few, small, local papers which ran the BMJ press release and thankfully Medscape ran it also. I can certainly assume that the information that these retinal findings can be attributed to accidental trauma and the literature saying they are from inflicted trauma only is not suported was not posted on the National Shaken Baby Prevention Web sites. Competing interests: None declared |
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Fikri M Abu-Zidan, Associate Professor, Head, Trauma GRoup Faculty of Medicine, UAE University, POBox 17666, Al-AIn UAE, Johan Johansen
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Dear Editor: We have read with great interest the recent published article in BMJ which discussed the retinal findings in a 14 months old child who sustained a head trauma because of a television tipover (1). Shaken baby syndrome was suspected and the child’s brother was removed from the family as a precaution to protect him. We have had similar cases and the doctors usually did not believe the story and occasionally labeled it as "The Flying TV Syndrome". Since we had not heard about this syndrome before, we had made a Medline search and were surprised to find four articles on this topic (2-5). All were retrospective studies. These papers collectively studied 306 patients. This type of trauma affects mainly children of less than 3 years old. Almost 70% (175/258) had head injury causing a high mortality of 12.4% (38/306). This type of injury occurs when young children try to climb using drawers as ladders causing the furniture or a television set to tipover them. It is our impression that ignorance of the existence of this trauma mechanism is common. Fikri M Abu-Zidan, Associate Professor, Head, Trauma Group and
Professor Johan Johansen, Professor of Neuroradiology,
Faculty of Medicine and Health Sciences,
United Arab Emirates University,UAE
References: 1. Lantz PE, Sinal SH, Stanton CA, Weaver RG Jr. Perimacular retinal folds from childhood head trauma. BMJ. 2004; 328:754-6. 2. Bernard PA, Johnston C, Curtis SE, King WD. Toppled television sets cause significant pediatric morbidity and mortality. Pediatrics. 1998;102(3):E32. 3. DiScala C, Barthel M, Sege R.Outcomes from television sets toppling onto toddlers. Arch Pediatr Adolesc Med. 2001;155:145-8. 4. Scheidler MG, Shultz BL, Schall L, Vyas A, Barksdale EM Jr. Falling televisions: The hidden danger for children. J Pediatr Surg. 2002;37:572- 5. 5. Jea A, Ragheb J, Morrison G.Television tipovers as a significant source of pediatric head injury. Pediatr Neurosurg. 2003;38:191-4. Competing interests: None declared |
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Scott J Robbie, SHO Ophthalmology Moorfields Eye Hospital Duke-Elder Eye Centre, St.George's Hospital, Tooting London, SW17 0QT
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From the point of view of one who has occasionally been in the position of having to offer an opinion in such cases, your review of the evidence regarding shaken baby syndrome was most welcome. I felt compelled to raise a number of points in response to some of the evidence quoted in the case report (Lantz et al. 'Perimacular retinal folds form childhood head trauma', BMJ 27 March 2004): Regarding retinal haemorrhages as a feature of the syndrome - I have not seen vitreo-retinal traction in adults result in extensive retinal haemorrhages and it is hard to conceive of 'acceleration/deceleration forces' resulting in haemorrhages in a baby given that the vitreous is a much less mobile structure in the latter. In addition the assertion of Greenwald et al. ('Traumatic retinoschisis in battered babies' Ophthalmology 1986;93:618-25) that such forces are responsible for both retinal haemorrhages and perimacular folds runs contrary to the findings of Duhaime et al.('Non-accidental head injury in infants-the shaken baby syndrome', New Engl J Med 1998;338:1822-9) who, in the only biomechanical study I have identified on the subject, found that the forces produced by shaking were likely insufficient to produce retinal haemorrhages. Similar studies have demonstrated that shaking is also unlikely to result in sufficient forces to cause subdural haemorrhage ('The shaken baby syndrome: a clinical, pathological and biomechanical study' Duhaime et al. J of Neurosurgery 1987; 66:409-15 and 'Shaken baby syndrome: fundamental question' Usinski, British Journal of Neurosurgery 2002;16(3): 217-219). Rising intracranial pressure, subdural haemorrhage and subarachnoid haemorrhage, however, are all well-documented causes of retinal haemorrhage. It is worth mentioning that Greenwald et al. use the term 'traumatic retinoschisis' in their article to describe what, as Torch points out in his editorial (in the same isssue), is essentially a large intra-retinal haemorrhage. It is not hard to imagine how such a haemorrhage (whatever it's aetiology) might result in the formation of perimacular folds in the absence of any tractional forces on the retina. Incidentally, according to Emerson et al. ('Incidence and rate of disappearance of retinal hemorrhage in newborns' Ophthalmology 2001 Jan; 108(1): 36-39) intraretinal haemorrhage was present in 34% of newborns in their study, with no intraretinal haemorrhage detected beyond the age of 4 weeks. This is obviously worth bearing in mind when examining neonates. I tend to agree that 'clinical and autopsy studies with appropriately matched controls are needed to determine the causal mechanisms of perimacular folds' - the disparity between the reported incidence of perimacular folds in the clinical case series (5%) and the sequential autopsy case series (50%) appears to confirm this. Certainly neither of the case series quoted in the article (Kivlin et al. 'Shaken baby syndrome' Ophthalomolgy 2000; 107: 1246-54 and Marshall et al. 'The spectrum of postmortem ocular findings in victims of shaken baby sydrome' Can J Ophthalmol 2001; 36: 377-83) makes any reference in their abstracts to the normal retinal changes occurring post-mortem; in fact, in researching this, I myself found details of normal post-mortem retinal changes rather hard to come by. If there was one point worth taking away from your review, aside form the need for good multidisciplinary teamwork and close scrutiny of the evidence when managing suspected cases, it was that the subject might benefit form less speculation and more good research. Whilst being the first to admit a degree of speculation on my own part, I nevertheless find it surprising that certain features of shaken baby syndrome should appear so rooted in myth. Competing interests: None declared |
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Heather Lohr, parent Huntingdon, PA 16652 USA
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Thank you for adding you perspective on the issue of retinal hemorrhages, perimacular folds and traumatic retinoschisis. I agree 100 percent that there needs to be much more research into this area of the "syndrome." When conducting even a search on the Internet for perimacular folds, one most often finds site after site, stating that this is caused by shaking and only by shaking. These sites do not contain research results. They are only advocacy sites for child abuse. If an average person who has not been charged checked out these sites, they would walk away believing that perimacular folds are pathonomic for shaking injury. I wondered about this and why I could never find any listing for nontraumatic causes. Then one day I found a report of 17 sets of eye balls. All had perimacular folds, all had been followed for 20 years (thus I assumed they were adults) and all had suffered increased intercranial pressure from a variety of etiologies, none of them traumatic. It may be time to look at the "classic shaken baby" and the case history reported by Lantz a little deeper. What else can be found in common besides alleged nonaccidental trauma in the "classic shaken baby" and tested and proved accidental trauma in Lantz's case report? Is there increased intercranial pressure? Is there hypoxic assault? What kind of hemorrhages were seen? Is it time to investigate whether it takes trauma at all to cause the findings? In regard to the reports on retinal hemorrhage from the birth process in neonates: One glaring problem just leaps out at me every time I read about these hemorrhages disappearing in four weeks. It is that there is no mention that any child in the studies had any intercranial pathology when examined. Where do these studies take into account the infant with a nondiagnosed subdural at birth which grows as diagnosed by a rapidly enlarging head circumference? If an infant is suffering from increased pressure that is undiagnosed and possibly transient, would retinal hemorrhages persist beyond that four-week period? It also does not escape me that if an infant were determined to have such problems they would receive prompt treatment and get specialized care and of course be labeled as abused. I am grateful that there is a growing number in the medical community who are stepping back for a better look. It is unfortunate that fear of the backlash is preventing more from doing the same. I can imagine the absolute upheaval of our court systems and the medical community if it is revealed that traumatic etiologies need not be necessary at all in this "syndrome." I feel that is the true motivation behind the constant drive to diagnose abuse even if there is none. How will all these "child advocate" doctors look then? Who will trust their medical opinion on anything after a revelation like that? Certainly I could never trust a doctor who doesn't know the steps of the scientific process, where first you form a hypothesis. It only becomes a theory after testing it. And if proved over and over again by testing, it may someday become a law. All shaken baby syndrome is, is a hypothesis, and any doctor who is willing to help convict parents and caregivers based on a hypothesis needs to have their licenses revoked and return to school where they can study these very basic steps that I learned in seventh grade. There is money and recognition to be had in the child abuse industry and that helps the current biased, dogma-based "science" to continue. This ongoing debate in the BMJ is warranted and certainly needed. I look forward to more debate! Competing interests: None declared |
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